左心耳在预测心房颤动发生脑卒中的作用

成为公共健康沉重负担的心房颤动和相关的血栓栓塞性脑卒中事件仍在以惊人的速度增长。心房颤动导致脑卒中的风险增加了5倍．．因此,预防脑卒中的心房颤动管理仍然是最关键的一方面。现在公认的重点预防措施就是规范抗凝,包括已使用很广泛的华法林和现在出现的新抗凝药如利伐沙班等。而且抗凝药的使用已有据可查。由于左心耳在心房鲡动血栓的发生中起关键作用,所以有目的性地去除或结扎左心耳来预防发生脑卒中就成了一种可替代的治疗方法,尤其是适用于那些不适合口服抗凝药的患者,,现就左心耳预测心房颤动发生脑卒中进行介绍。     

Percutaneous Left Atrial Appendage Ligation for Stroke Prevention in Atrial Fibrillation

Prevention of thromboembolic complications in atrial fibrillation remains a tremendous clinical challenge. Knowledge that the left atrial appendage (LAA) is the most common anatomical origin of cardioembolic strokes1 has been the main motivation to develop clinical and procedural strategies to exclude the LAA from the circulation, either surgically or percutaneously. This review discusses the rationale behind these strategies, their relative merits, and future prospects for LAA exclusion strategies.     

左心耳封堵术在预防心房颤动患者脑卒中的研究进展

心房颤动是最为常见的心律失常之一,极易引起脑卒中事件。左心耳是血栓形成的主要部位,封堵左心耳可减少心房颤动血栓的发生率。现就封堵左心耳来预防心房颤动患者脑卒中的研究做一综述。     

左心耳结构复杂性与非瓣膜性心房颤动患者左心耳血栓形成的关系

目的:探讨左心耳结构复杂性与非瓣膜性心房颤动(NVAF)患者左心耳血栓形成的关系。方法:连续入选拟行射频消融术治疗的NVAF患者295例,记录病史资料和化验指标,进行CHA2DS2-VASc评分。行经食道超声心动图和计算机断层扫描血管造影(CTA)检查了解左心耳有、无血栓形成,以此将患者分为血栓组(n=42)和无血栓组(n=253)。应用CT影像后处理系统对左心房CTA影像进行三维重建,获取每例患者的左心耳形态,将左心耳形态分为单纯型和复杂型两类。分析左心耳血栓形成与各项潜在危险因素的关系。结果:血栓组非阵发性心房颤动(76.2%vs 18.2%)、复杂型左心耳比例(66.7%vs 45.1%)显著高于无血栓组(P均<0.01)。此外,血栓组患者的年龄、心房颤动病程、左心房前后径、B型利钠肽、血尿酸、CHA2DS2-VASc评分均大于无血栓组(P均<0.05)。相对于无血栓组,血栓组患者的高血压、糖尿病、冠心病、慢性心力衰竭、脑卒中/短暂性脑缺血发作/血栓栓塞以及血管疾病的患病率更高(P均<0.05)。多因素Logistic回归分析显示,复杂型左心耳(OR=4.129,95%CI:1.413~12.069)、心房颤动病程(OR=1.021,95%CI:1.006~1.036)、非阵发性心房颤动(OR=13.910,95%CI:4.563~42.406)与CHA2DS2-VASc评分(OR=2.580,95%CI:1.115~5.966)均是左心耳血栓形成的独立危险因素(P均<0.05)。结论:复杂型左心耳为NVAF患者左心耳血栓形成的独立危险因素。     

Simultaneous Right and Left Atrial Appendage Thrombus in a Patient with Atrial Fibrillation: A Lesson to Remember

We report a case of simultaneous right and left atrial appendage thrombi in a 76‐year‐old‐man with atrial fibrillation. Although transesophageal echocardiography is considered a routine diagnostic procedure, complete and comprehensive visualization of both atrial appendages is of paramount importance, particularly with the introduction of new therapeutic options like left atrial appendage exclusion devices. We expect to raise awareness among clinicians of the prevalence and implications of bilateral atrial appendage thrombi in common clinical practice.     

Left Atrial Appendage Stenosis

We describe an unusual case with an anatomic narrowing at the opening of the left atrial appendage demonstrated by two-dimensional color Doppler and continuous-wave Doppler transesophageal echocardiography.     

The Left Atrial Appendage: Target for Stroke Reduction in Atrial Fibrillation

A patient with atrial fibrillation (AF) has a greater than 5% annual risk of major stroke, a 5-fold increase compared to the general population. While anticoagulation remains the standard stroke prevention strategy, the nature of lifelong anticoagulation inevitably carries an increased risk of bleeding, increased stroke during periods of interruption, increased cost, and significant lifestyle modification. Many patients with atrial fibrillation have had their left atrial appendage (LAA) ligated or excised by surgeons during cardiac surgery, a decision based largely on intuition and with no clear evidence of efficacy in stroke risk reduction. The observation that 90% of the thrombi found in nonvalvular AF patients and 57% found in valvular AF are in the LAA, triggered significant interest in the LAA as a potential therapeutic target. Until recently, the results were inconsistent, and high rates of incomplete occlusions precluded the medical community from confirming a definite relationship between LAA and stroke. As a result, anticoagulation is still the recommended first-line stroke risk reduction in AF, and the American College of Cardiology/American Heart Association guidelines recommend LAA exclusion only with surgical ablation of AF or in the context of concomitant mitral valve surgery.A handful of devices have been developed for LAA exclusion. This includes percutaneous options such as WATCHMAN™ Left Atrial Appendage Closure Device (Boston Scientific Corporation, Marlborough, MA), hybrid epicardial devices such as the LARIAT Suture Delivery Device (SentreHEART, Inc., Redwood City, CA), and epicardial surgical devices such as AtriClip® LAA Occlusion System (AtriCure, Inc., West Chester, OH). Studies of the Watchman device have shown noninferiority to Warfarin in stroke prevention and this device has recently gained approval from the U.S. Food and Drug Administration (FDA) following lengthy delays due to safety concerns. The Lariat device, which received 510K clearance by the FDA for tissue approximation but not LAA exclusion, has been the target of significant criticism due to serious procedural safety concerns and high incomplete closure rates. The surgical AtriClip has been FDA approved since 2009 and is currently the most widely used LAA exclusion device placed through an epicardial approach. Small studies have shown excellent reliability and success of complete LAA closure with the AtriClip device, which is implanted through an epicardial approach. Currently, we are conducting a multicenter trial to demonstrate the stroke prevention potential of this epicardial device through a short (45 minute), stand-alone, minimally invasive procedure in lieu of lifelong anticoagulation in patients at high risk of bleeding.